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61 Cards in this Set
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Peripheral Vascular Disease (PVD)
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Refers to perfusion disorders related to the blood vessels' ability to deliver O2 and nutrients to and to remove waste products from body tissues
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PVD
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1. Peripheral Arterial Disease (PAD)
2. Peripheral Venous Disease (PVD) |
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Risk Factors: PAD
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**cigarette smoking
*hyperlipidemia *HTN *diabetes mellitus Others: obesity, hypertriglyceremia, hyperuricemia, family history, sedentary lifestyle, stress, and increased homocysteine |
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PAD
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Describes a wide variety of conditions affecting arteries in the neck, abdomen, and extremities
Leading cause is atherosclerosis -- a gradual thickening of the intima and media of arteries, which leads to progressive narrowing of the vessel lumen. (decreased blood flow) |
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Arterial PAD
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Acute arterial occlusive disease
Chronic arterial occlusive disease Aneurysm |
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Arterial Disease/Chronic
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Progresses slowly
Prolonged ischemia leads to atrophy of the skin and underlying muscles. Minor trauma to the feet may result in delayed healing, wound infections, and tissue necrosis, especially in the diabetic patient. (decreased arterial blood supply) |
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Manifestations (Chronic)
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*Intermittent Claudication--pain that is precipitated by a consistent level of exercise, resolved within 10 minutes or less with rest and is reproducible.
Parasthesia, numbness/tingling toes or feet/burning pain Loss of both pressure and deep pain sensation (pain is from lactic acid accumulation) |
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Manifestations (cont)
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Skin -- thin, shiny, taut, dry
Loss of hair on lower legs Thickened, brittle nails Decreased or absent pulses Elevation pallor (legs up = decreased perfusion) Reactive hyperemia (redness of foot/dependent rubor) Rest pain (late sign) indication that they need surgery |
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Arterial Disease/Acute (Acute arterial occlusion)
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Occurs suddenly, without warning, abrupt onset
Causes: embolism, thrombosis, or trauma (blood supply is cut off) *Medical Emergency* |
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Manifestations (Acute)
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Six P's
*Pain *Pallor *Pulselessness *Parathesia *Paralysis *Poikilothermia (limb takes on temperature of the environment) |
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Complications of Arterial Disease
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Atrophy (skin & muscle)
Infection Ischemic Ulcers Gangrene Amputation |
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Ischemic Ulcers (Arterial)
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Most common over bony prominences on toes, feet, lower legs, lateral malleolus
No edema Minimal drainage Rounded, smooth, punched out appearance Rarely pruritis or dermatitis |
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Goals of Therapy
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Adequate tissue perfusion
Relief of pain Increased exercise tolerance Intact healthy skin and extremities |
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Treatment: Medical
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Risk factor modification
Drug therapy Exercise therapy Conservative Interventional Radiology |
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Risk Factor Modification
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Smoking cessation
Aggressive treatment of hyperlipidemia Ideal body weight achieved and maintained Tight control of HTN and DM |
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Drug Therapy (Chronic)
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Antiplatelet Agents -- ASA, Plavix, Ticlid
Drugs for intermittent claudication Trental - increases erythrocyte flexibility and decreases blood viscosity. (blood flows better) Pletal (newest) - inhibits platelet aggregation and increases vasodilation *Need to treat chronic afib with long term anticoagulation (Coumadin) |
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Drug Therapy (Acute)
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IV heparin
Intraarterial infusion of a thrombolytic agent (TPA - Tissue Plasminogen Activator) |
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Exercise Therapy/Chronic
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Formal exercise training program
Walking - walk daily until the point of pain *Improves oxygen extraction in the legs and skeletal muscle metabolism.* |
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Conservative
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Protect extremity from trauma-avoid chemicals/heat, footwear-soft/roomy/protective
Decrease vasospasm - avoid heat/cold Prevent and control infection -careful inspection, cleansing, and lubrication Maximize arterial perfusion-heels kept free of pressure Feet in the dependent position Feet in arterial position=dependent position |
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Interventional Radiology
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Percutaneous Transluminal Balloon Angioplasty - through femoral artery, balloon inflated, cracks intimal shell and stretches media
Atherectomy - laser tipped, burns plaque before dilation Intravascular Stents - metallic devices placed in the artery after angioplasty **Post procedure - monitor site for bleeding, monitor pulses, bed rest (Head flat for 6 hours - monitor peripheral pulses) |
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Treatment: Surgical
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Peripheral Arterial Bypass Graft - vein or synthetic graft bypasses/carries blood around lesion
Endarterectomy-opening artery and removing obstruction (plaque) Patch Graft Angioplasty - open artery, remove plaque, sew a patch to opening to widen the lumen Amputation (beyond surgical repair = amputation) Figure 37-6 |
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Implementation: Post-op care for Arterial Bypass
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*Monitor extremity closely-CSM, pain, pulses
*loss of pulses, numbness & tingling (embolism through bypass graft) -notify MD immediately* Keep heels free from pressure Avoid knee flexion OOB Home Care - manage risk factors, inspect legs, feet daily for temp & color changes, clean all wounds, comfortable/round toe shoes/insoles Teaching Plan 37-5 (p.296 Lewis) |
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Venous PVD
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Chronic Venous Insufficiency
Venous Ulcers |
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Chronic Venous Insufficiency (CVI)
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CVI - A condition where valves in extremities are unable to close, allowing blood to flow backward into dilated veins (retrograde backflow of blood)
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Causes: CVI
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Vein incompetence, vein obstruction, congenital venous malformation, AV fistula, and calf muscle failure
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Patho/Manifestations (CVI)
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Incompetent valves in deep vein
Increased pressure leads to serous fluid and RBC's leaking from capillaries and venules into the tissue which leads to edema Enzymes in the tissue breakdown RBC's which leads to the release of hemosiderin which causes brownish skin discoloration Varicose veins may be visible |
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Patho/Manifestations (CVI)
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Skin and SC tissue around the ankle is replaced with fibrous tissue, this leads to thick, hardened, contracted skin
Pain - aching pain after standing for a long time, relieved by walking or elevation -pressure or cramp-like sensation -leg cramps at night |
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Venous Ulcers
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Leg ulcers are associated with chronic venous insufficiency and accumulation of deoxygenated blood
Results from damage to the integrity of skin and tissues |
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Manifestations/Venous Ulcers
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*Classically located above the medial malleolus
Wound margins irregularly shaped Tissue is a ruddy color Partial thickness Extensive drainage Painful Very itchy/dry around |
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Complications
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Wound infection
Cellulitis (surrounding tissue becomes infected) Secondary lymph edema Thrombophlebitis Amputation Rupture (varicose veins) |
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Venous Disease: Treatment
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Medical:
Prevention Compression Moist Dressing Optimize Nutrition Radiant Heat Bandage (alternate therapy) Sclerotherapy (varicose veins) |
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Treatment: Prevention
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Avoid trauma to limbs
Daily moisturizing-decrease itching, prevent cracking Assess S&S of infection Avoid sitting/standing with feet dependent of rlong periods/avoid leg crossing Elevation-above level of heart Daily walking (once ulcer has healed)-followed by elevation Maintain ideal body weight Avoid constrictive clothing |
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Treatment: Compression
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**Most useful treatment for venous stasis ulcers, leads to decreased venous stasis and edema
Variety of options-elastic wraps, unna boot, custom fitted compression stockings, velcro wrap, sequential pneumatic compression devices Need to put on before client gets OOB Need to assess arterial status --ABI >0.8 Can't use with active cellulitis Arterial & Venous Disease together = NO COMPRESSION |
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Treatment: Dressings
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*Needs to be used in conjunction with extrinsic compression
Moist more effective than dry dressings for healing Moist transparent film (tegaderm) Hydrocolloids (duoderm) May need aquacel to absorb |
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Treatment: Nutrition
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A balanced diet with adequate protein, calories, and nutrients
Nutrients most important for healing include: protein, vitamins A and C, and zinc Patients with DM-maintain normal glucose Overweight with CVI-weight reduction diet *If active venous ulcers-no weight reduction |
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Treatment: Sclerotherapy
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Direct IV injection of sclerosing agent (sodium tetradecy) into superficial varicose veings - causes inflammation, vein thrombosis, disappear
**Post procedure -Elastic wrap for 24-72 hours -Compression stockings for prevention Laser therapy option for superficial varicosities |
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Treatment: Surgical
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Ligation-(varicose)-of entire vein and dissection and removal of its' incompetent tributaries
Split thickness skin graft-ulcer is debrided, varicosities removed, veins ligated before tissue from a donor site is applied Bioengineered skin |
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Treatment: Surgical/Post Op
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Monitor CSM, edema, temperature
Check pedal pulses *Bruising/discoloration is normal Elevate legs 15 degrees to prevent venous stasis & edema Compression stockings - remove & reapply every 8 hrs |
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Assessment: Physiological Integrity
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Health history
Pain Family history Medications Previous vascular surgery Presence of risk factors |
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Assessment (cont)
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B/P
Inspection: extremity Palpation -pulses -Temperature Auscultation: bruit (femoral) |
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Assessment: Diagnostic Studies
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Doppler ultrasound
Ankel-brachial index Duplex imaging Angiography Magnetic resonance angiography |
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Doppler Ultrasound
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Measures blood flow velocity, direction of flow
Blood pressures measured in thigh, below knee and at ankle Useful in obtaining pulses in lower extremities when they are not palpable |
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Ankle-brachial Index
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Obtained by dividing ankle SBP by highest brachial SBP
Normal = 1.0 Abnormal <1.0 *Lower the ABI the worse the PAD *ABI - useful in monitoring lower extremity bypass graft patency |
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Duplex Imaging
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Uses a doppler to map blood flow throughout the entire region of an artery
Gives anatomic and physiologic data about vessels |
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Angiography (Invasive)
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Further refines data obtained in duplex imaging
Useful when intervention is indicated Involves the use of dye - toxic to kidneys iodine allergy **done through femoral artery-monitor site for bleeding, pedal pulses, CSM, bed rest |
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Magnetic Resonance Angiography (MRA)
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Angiogram done by MRI, using dye that is not toxic to the kidneys
**being used more** |
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Assessment: Safe Effective Care Environment
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Knowledge of ways to prevent LE (lower extremity) injury
Knowledge of care of LE injuries |
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Assessment: Psychosocial Integrity
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Body image changes related to skin impairment
Role function changes related to activity intolerance or skin impairment How client copes with the disease process and necessary life style modifications |
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Analysis/Diagnosis
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Acute pain
Impaired skin integrity Ineffective tissue perfusion Disturbed body image Ineffective role performance |
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Summary/Outcomes
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Blood flow to and/or from affected extremity will improve
Client will adopt health seeking behaviors to minimize progression of PVD As much limb as possible will be preserved |
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Arterial or Venous?????
Parasthesia |
Arterial
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Arterial or Venous????
Heavy ulcer drainage |
Venous
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Arterial or Venous????
Edema around the ankles |
Venous
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Arterial or Venous????
Gangrene over bony prominences, toes, or feet |
Arterial
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Arterial or Venous????
Decreased peripheral pulses |
Arterial
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Arterial or Venous????
Brown pigmentation of the legs |
Venous
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Arterial or Venous????
Thickened brittle nails |
Arterial (decreased perfusion)
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Arterial or Venous????
Ulceration around the medial malleolus |
Venous
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Arterial or Venous????
Pallor on elevation of the legs |
Arterial
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Arterial or Venous????
Dull ache in calf or thigh |
Venous
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Arterial or Venous????
Pruritis |
Venous
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